| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
736 |
722 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
814 |
799 |
$13K |
| D0330 |
Panoramic radiographic image |
288 |
281 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
111 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
316 |
308 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
558 |
543 |
$8K |
| D0272 |
Bitewings - two radiographic images |
889 |
871 |
$7K |
| D1120 |
Prophylaxis - child |
291 |
281 |
$5K |
| D1351 |
Sealant - per tooth |
211 |
64 |
$4K |
| D0274 |
Bitewings - four radiographic images |
312 |
312 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
37 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
26 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
400 |
340 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
40 |
$925.78 |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
90 |
$875.00 |